Provider Demographics
NPI:1942931761
Name:DIAZ, DAMARIS ANDREA (PA-C)
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:ANDREA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 FOUR MILE DR APT 4
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3815
Practice Address - Country:US
Practice Address - Phone:240-548-7895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5853363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical